A federal agency’s surveys of Allegiance Specialty Hospital this year revealed faults representing an “immediate jeopardy” to patient health and safety.
All patients were subsequently discharged from the hospital as ASH addressed a series of deficiencies to restore compliance with Medicare requirements as quickly as possible.
“Based on the findings of these surveys, the hospital was involuntarily terminated from the Medicare program on May 5, 2017,” according to Bob Moos, a public affairs specialist for the Centers for Medicare and Medicaid Services, Region 6. “CMS issued final notice of termination of Medicare participation on April 20, 2017, for ongoing failure to provide a safe environment to suicidal patients, adequate staff training for the management of aggressive behavior, and the appropriate use of restraints and seclusion.”
ASH addressed the developments in a press release this week.
“This action does not affect the hospital’s license nor its ability to accept patients with private insurance,” according to the statement Allegiance Specialty Hospital CEO Karen Ross provided to the News Herald via email Thursday. “CMS has an obligation to ensure all providers meet certain conditions in order to participate in Medicare. Allegiance supports CMS’ obligations and firmly believes the Hospital meets all of the requirements to participate in Medicare.”
As of the two surveys the hospital was out of compliance with five Medicare Conditions of Participation, according to an April 20 letter from CMS Enforcement Branch Manager Ginger Odle, based in Dallas. They include deficiencies in the ASH Governing Body, Patient Rights, Quality Assurance and Performance Improvement, Nursing Services and Utilization Review.
The City of Kilgore owns the Laird Memorial Hospital property and leases the facility to Allegiance Specialty Hospital as the primary tenant. Sub-leases include the Christus Good Shepherd Emergency Department and the Kilgore College Health Science Center – those operations are unaffected by the Allegiance's renovations.
ASH officials say they’re committed to operations here and are working to address the agency’s concerns without delay: “The hospital has already started the process of getting reapproved as a Medicare provider and welcomes the opportunity for another survey.”
The most recent, 42-page inspection report issued by CMS after the late-March review notes a variety of issues and includes notes from interviews with multiple staff members including administrators and caregivers.
Michael Shulze, a Louisiana attorney acting as spokesperson for the hospital, says the hospital disagrees with some of the findings, but is making a concerted, good faith effort to comply with directives from CMS.
“All of the physical plant things that they had pointed out this time had been approved on the previous surveys,” he noted.
That said, the hospital doesn’t plan to challenge the findings. Rather, ASH leaders immediately set to remedying the survey concerns.
“There is an absolute need to make sure the patients are safe, and CMS has an important role in making sure that happens. We support it. We absolutely support it,” he said. “This provider acted the way CMS would expect providers to act, which is to immediately address it. They truly did. As soon as they heard something they needed to change, they immediately dropped everything and worked on the fix.”
ASH is a 51-bed acute care hospital, Moos noted in his summary of the recent enforcement action, and Texas Department of State Health Services personnel completed two surveys at 1612 S. Henderson Blvd. this spring – on Feb. 23 and in a follow-up March 31 – through CMS’ oversight of accrediting organizations.
The facility had ‘Immediate Jeopardy’ during the first survey, he added, and it persisted through the re-visit.
In a rebuttal letter May 5, Schulze maintains that immediate jeopardy was not present in the second visit and seeks a “positive resolution” to a misunderstanding.
“The Hospital went to extraordinary efforts to correct each and every one of the deficiencies” found in February, Schulze writes, and any un-addressed faults were discovered later: “CMS cannot terminate the Hospital’s provider agreement due to an alleged IJ based on deficiencies of which the Hospital had no notice or opportunity to correct.
He noted later, “An immediate jeopardy determination is a very serious matter. It is an important administrative evaluation tool designed to help safeguard patient safety, but it must be accurately and fairly applied.”
In his summary Friday morning, Moos detailed multiple ligature risks in various areas of Allegiance Specialty Hospital’s portions of the facility, including in the behavioral health unit.
“These ligature risks were easily accessible to suicidal patients and patients with aggressive behaviors that could be used to harm themselves or others,” Moos reported. “The risks remained uncorrected during the follow-up survey.”
Exposed pipes from toilets and flush tanks as well as large swan-neck faucets and winged handles in bathrooms, including in seclusion rooms, could give suicidal patients a means to hang themselves.
The surveys also revealed “drop-down ceiling tiles that could easily be removed, light fixtures over bath tubs with exposed wiring, uncovered light fixtures in the seclusion rooms that were easily accessible by patients, and exposed long electrical cords that were easily accessible by patients that could be used to harm themselves or others,” Moos reported.
According to Schulze, those elements have been present through multiple surveys dating back to 2008, without issue.
Likewise, “The hospital had a waiver specifically approving the drop-down ceiling,” he said. In the recent surveyor’s opinion, “It’s a safety risk for the patients. Even though it’s never been a problem.”
Regardless, Schulze added, ASH acted as requested.
“The hospital, rather than arguing about it, simply went ahead and agreed to replace and improve the ceiling,” he said, spending approximately $100,000 plus another $30,000 for rapid completion – no patients could be on-site during the work.
According to the CMS report, Allegiance stopped admitting new patients after the Feb. 23 survey and none were present in the facility at the time of the follow-up a little more than a month later.
While the ceiling was OK’d in March, Schulze said, that visit spawned a list of new deficiencies that hadn’t been noted before.
Among other issues addressed during the March visit, CMS’ surveyor noted various staff members were misinformed about training requirements. For example, training for physical de-escalation of confrontations is set at 16 hours (two days), but ASH employees complete eight hours of training.
Two staffers interviewed March 30 did not understand the facility’s complaint/grievance policy and procedures for patients, the surveyor reported, and telephone numbers given to patients to report grievances were incorrect.
According to Moos’ breakdown, “Staff were not adequately trained in the management of patients with aggressive behavior, and appropriate use of restraint and seclusion. An action plan to address patient falls with injury had not been fully implemented at the time of the March 31, 2017, survey and placed patients at risk of additional falls with injury.”
The full report also spotlights a variety of Infection Control problems discovered during a tour of the facility March 30, ranging from “visibly dirty” materials and equipment to mildewed bathroom fixtures, improper storage of clean/dirty items and a damaged windowframe.
The acute care hospital is not yet taking on new clients – Allegiance Specialty Hospital has been focusing on renovations and repairs of problem areas for weeks in addition to fixing policies and procedures.
“Acting on this notice, the hospital immediately started working by upgrading the ceilings, updating the facility’s faucets and other hardware, and making all of the other necessary changes,” according to Thursday’s release from ASH: Those upgrades are now complete, and “...the hospital is focused on getting reinstated as a Medicare provider by completing the process established by CMS.”
If it chooses, the hospital has until June 19 to challenge the enforcement action before an administrative law judge of the U.S. Department of Health and Human Services Departmental Appeals Board.
That’s not the plan, Schulze said. The goal is full compliance, making sure CMS is content with Allegiance Specialty Hospital’s efforts.
“Actions speak louder than words,” he said, “so when the hospital was told to put in a solid ceiling .. they didn’t argue, they simply did it. What the hospital was asked to do, they did, and they did it on time.
“It wasn’t even a matter about money. They didn’t even consider whether or not they were going to be able to recoup all the money they were putting in the renovations. They feel like they have an obligation to provide these services to the community because mental health services are in short supply.”
According to Odle’s April 20 letter, “a new Medicare provider agreement will not be accepted until it has been determined that the reason for termination of the previous agreement has been removed and there is reasonable assurance that it will not recur.”
CMS will set a timetable to monitor whether requirements have been satisfied.
“During this period,” Odle wrote, “the facility must fulfill, or make satisfactory arrangements to fulfill, all of the statutory and regulatory responsibilities of the previous agreement.”
Until compliance is restored, Moos noted, care is available to those who need it (per Texas Department of State Health Services) as there are seven acute hospital within 35 miles of ASH.
According to the facility’s statement Thursday, “In 2008, Allegiance pledged to expand the scope of health care services in the Kilgore community by offering inpatient and outpatient psychiatric services in addition to general hospital services. Allegiance remains committed to providing these vital services to the Kilgore community.”